Episode 22: Dr. Leigh Frame, PhD on Vitamin D & The Immune System and Microbiome

Show Summary:

Today we have Dr. Leigh Frame joining us!

Dr. Frame is the Associate Director, Resiliency and Well-being (R&W) Center, and Assistant Professor, Department of Clinical Research and Leadership, George Washington School of Medicine and Health Sciences. She is also the founding Chair, GW Microbiome Research Interest Group, George Washington University

Today we are going to discuss vitamin D and it’s role with the immune system and microbiome!

TIMESTAMPS:

0:00 - Introduction

1:08 - Dr. Frame’s personal health story

4:17 - Why is vitamin D important?

6:22 - What are some of its most important functions?

8:00 - What is the optimal level of vitamin D?

10:48 - How do you optimize absorption?

15:37 - Sun exposure vs supplementation

19:28 - Vitamin D2 vs D3

21:01 - Role of magnesium and Vitamin K2

24:18 - Role of Vitamin D in the immune system

26:40 - Vitamin D & Upper Respiratory Infections

28:52 - Does vitamin D get sequestered in body fat?

31:35 - Vitamin D and Infections

36:41 - Vitamin D3 vs 1-25 Hydroxy D levels

37:45 - The microbiome and vitamin D

40:20 - Dr. Frame’s morning routine

41:22 - Dr. Frame’s favorite podcast

42:11 - What brings Dr. Frame joy

43:11 - Dr. Frame’s social media and current work

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Full Episode Transcript:

SPEAKERS: Dr. Andrew Wong, Dr. Leigh Frame

Welcome to the Capital Integrative Health podcast, a podcast dedicated to transforming the consciousness around what it means to be healthy and understanding the root causes of both disease and wellness. I am Dr. Andrew Wong, co-founder of Capital Integrative Health, an integrative practice committed to expanding access to holistic root cause medicine to the global community.

Today we're honored to have Dr. Leigh Frame join us. She is the Associate Director of the Residency and Well-being Center and the Assistant Professor in the Department of Clinical Research and Leadership at the GW School of Medicine and Health Sciences right here in Washington DC. She also has many other appointments and is the founding chair of the GW Microbiome Research Interest Group at George Washington University and has a special expertise in both clinical nutrition but also vitamin D. So today we're going to discuss the role with Dr. Frame here about vitamin D and its role, a really important role with the immune system and the microbiome. So if you have any questions about how vitamin D works and how to use it, this conversation is for you.

Dr. Wong

Welcome, Dr. Frame.

Dr. Frame

Well, thank you so much. This is definitely one of my favorite topics, so I'm excited to nerd out on it with you.

Dr. Wong

So excited to dive into this with you here. Before we start with vitamin D. We just wanted to ask you a general question which we generally asked our guests, which is in your background you know as a researcher, as a Ph.D. integrative health. What motivated you to pursue research and integrative health in general?

Dr. Frame

Oh, great question. I actually had a personal experience, which I feel like, is not uncommon in our field. People went through the traditional health care system and it didn't work out for them, I was one of those people. It took me 30 years of my life to get diagnosed with celiac disease. I went to every doctor, I had arthritis from the time I was seven which is obviously not normal but they couldn't figure out why I had it so “well it must just be something about you”, and as you can imagine I was a little frustrated by that answer and that answer was not something I was willing to accept. So I took it upon myself to figure out what was wrong with me and started to do a lot of sort of complementary therapies thinking that maybe they'll help me. I was seeing an acupuncturist and I will tell you it was my acupuncturist who figured it out because he was willing to think about things in a slightly different way like, “maybe it could have something to do with your diet” which is now I think something that's much more of a mainstream concept but even 10 years ago was still pretty fringe “oh diet can't possibly lead to those type of syndromes” but it does. And so that's what really motivated me to fully embrace integrative health because it can do a lot of things that unfortunately our standard healthcare system is not very good at.

Dr. Wong

And that's life-changing just knowing that there's a root cause and something you can do about it to really move that needle.

Dr. Frame

Exactly, rather than just continuing to treat my symptoms which is what every other doctor had told me to do.

Dr. Wong

Yeah. And I think that's very humbling too. We know that you know in traditional medicine right we kind of value the medical and this whole idea of like medical care but you know all of the healthcare professionals, acupuncturists, massage therapy, physical therapy, chiropractic, nutrition, you know integrative practitioners in general of course naturopathic medicine, integrative functional medicine you know we focus a lot on here too. I mean everyone has and I probably you know haven't named many many others but the idea is that we all have something to contribute to the you know, the care of our patients. And I think when we listen really deeply and to our patients but also to our colleagues you know that might have different expertise than us and have that different angle at which you might be able to solve that that mystery that's going on so that's really great.

Dr. Frame

Yeah. I wholeheartedly agree. We see that a lot in the integrative medicine programs at GW the students that we teach are quite diverse and I think that's part of the reason our discussions are so good because of exactly that people are bringing different perspectives, different insights and we end up coming to a much better solution by having everyone together in that group then you would if you just had someone with one or two perspectives.

Dr. Wong

Yes and as we always say here it takes a village you know different perspectives. Well let's start broad with vitamin D. So first of all what is vitamin D? Is it even a vitamin? Let's talk about that.

Dr. Frame

Great question. So vitamin D is very complicated. It is a vitamin in the sense that we need to get enough of it to live but our bodies actually make vitamin D and that's kind of unusual. Typically vitamins are ones that we don't make, they're things that you need to get externally like for instance vitamin C, while some animals make their own vitamin C we don't, and so it's vital for us to get in our bodies. But we make it from sun exposure so that means it's not exactly a vitamin but it kind of is but almost more importantly it's a hormone. And because it's a hormone it has really broad effects. I like to explain like, if you didn't have enough testosterone in your body you could imagine there'd be lots of different effects things that would go wrong because you didn't have that hormone and that's the case with vitamin D and I think that's maybe somewhat confusing for researchers as well as the lay public they're like, “well, can vitamin D really do all these things?”. And it's because it's a hormone it has these really broad effects that it can affect everything from your skin to your immune system to your bones to I mean really you name it there's an effect from vitamin D.

Dr. Wong

So hormones are these chemical messengers that really have what we call pleiotropic effects or different effects in different organs it really does affect you know the whole body that's why when you do a PubMed you know google scholar you see your name up there talking about vitamin D research and many others and basically we know that you can really take any organ system in the body any system and you'll see that vitamin D has an effect, is that right?

Dr. Frame

Correct that is correct and some of them are it's more important than others you know. We figured out bones pretty quickly because without enough vitamin D your bones literally softened. So it was easy for us to figure out “okay here's the link we've got that one” but a lot of the other ones are a little bit more nuanced like it's about exactly how the immune system functions and that can be slightly turned up, slightly turned down, it's not maybe quite as obvious as say with bone.

Dr. Wong

What are some of the other primary roles in the body for vitamin D and beneficial effects besides bone health?

Dr. Frame

So I like to think of vitamin D as kind of the conductor of a symphony and so within your body, you have various processes going on many of them are linked to your immune system and vitamin D turns up this one turns down that one tells this one hold on we don't need you quite yet and it's really telling them how to do their job and it does that actually through gene expression which that's something that maybe people will understand why vitamin D is so broadly effective is it actually changes the way genes are expressed, how much they're expressed, how often they are expressed or if they're not expressed at all and it does that by directly binding to the promoter region. So it's actually binding to the DNA and changing whether it's expressed or not. So that's what it's doing right, it's saying okay more of you, less of you and it's making sure that everything's hopefully working correctly for the exact point in time. So most of the time it's going to be homeostasis, it's going to be balanced, other times you have a pathogen and you need to ramp up inflammation right you need that infection to be crawled down and it needs to be very quick then you also have to turn it off again because we don't want to have chronic inflammation and all of these things vitamin D has a role to play.

Dr. Wong

So that's really huge that vitamin D changes gene expression because as you know it's not about the gene, it's about the epigenetics, the basic expression on that gene. What is the optimal level do you think of vitamin D is the research out there to support a certain level or a certain range and then we can talk about how to optimize levels a little bit later?

Dr. Frame

Yeah, so the perfect amount of vitamin D is actually hotly debated and there are a lot of people there with a lot of opinions but luckily there is some actual science and research that we can talk about and what you'll see in a lot of clinical labs they'll say the minimum for vitamin D is 30 or 32 nanograms per milliliter and that is based on pretty good science based on bone health. There's one study in particular that I always find really interesting where they looked at autopsies of people who had car accidents so they died for reasons, not due to their health and they looked at their bones and their vitamin D status and they found that if you were less than 32 nanograms per milliliter there was signs of bone softening which is, was much higher than we thought prior to that study even for bone health so all right now we're going to say you have to have at least 32 because you get studies like that but those are still based on bone health and the amount that you need for the immune health and some of these more subtle nuance things is actually higher than for bone health. So when we talk about those, we're thinking at least 40. Sometimes people were talking about 60 there's even some indication that maybe it's 80 or 100. We're talking about really high levels and that's difficult to have a conversation about when you don't have these known factors but when we look by and large in literature, we see that 40 to 60 is generally looking pretty safe though that's a good area to be in above 60 there may be some benefits but who knows there could be some long-term effects that we don't know about but the one thing that I really like to emphasize with vitamin D is while it's a fat-soluble vitamin and typically we get scared about too much of fat-soluble vitamins because they're stored in the fat, vitamin D isn't exactly stored in that way and we actually have four different pathways to eliminate excess vitamin D. So it's hard to overwhelm four different pathways so I don't get too concerned about having too much vitamin D for that reason and also when you go outside you can make 10, 15,000 international units of vitamin D in one go really easily you know 15 minutes on a peak day within a bathing suit. So now we're talking about delivering large amounts so when we are giving vitamin D I don't worry as much about that as I would say with vitamin A there I'd be really nervous about having too high of a blood concentration or giving too large a dose of vitamin A, vitamin d is a little bit more regulated in terms of going too high so aiming for that 60 might be better than aiming for 40.

Dr. Wong

Got it. Okay so now that we know we're looking at 40 to 60. Let's say, how do we optimize levels and absorption of vitamin D?

Dr. Frame

So vitamin D is a fat-soluble hormone which means it is absorbed better with fat. So that's the first thing is if you're going to take a vitamin D supplement make sure you're having it with fat in nature. It typically comes with the fat right so if you're going to have salmon or some other fatty fish it has vitamin D in it, it also has fat those are also, the real, the only good vitamin D sources in the diet because everything else is just really small amounts even fortified milk the amount that was added to was determined at the turn of the last century and it's really kind of an outdated amount. It's, it's a very tiny, tiny it's kind of laughable actually the amount that's in milk so that's not really a great source even though it says it on the package you know vitamin D there is some in eggs there's also some in irradiated mushrooms but there are some issues with that which we'll talk about I think in a little bit we talk about D2 versus D3.

Dr. Wong

Great! I love it.

Dr. Frame

So, I'll show that for now but so generally you're not getting it from your diet or you're not going to get enough from your diet because we were really designed to be outside our bodies are designed to be exposed to the sun and the majority of our vitamin D status comes from sun exposure. Now that's not true anymore, right? Most people you and I right now we are sitting inside and not making any vitamin D and if you live in the northern latitudes above 35 degrees north you're not getting in the winter no matter where you are whether you're inside or outside you just can't make it because the angle of the sun is not sufficient so that's when we start to really think about supplements, particularly during the winter for people who you know are living our modern life and aren't going outside and one of the nice things about vitamin D because it is a hormone. Supplements actually are a good source whereas a lot of things in nutrition we really want to look to food it's better to get it in the food matrix it's healthier to get it with all these other elements but luckily in this case that doesn't seem to be the case for vitamin D and delivering it via supplement is a good alternative.

Dr. Wong

And even, even for those of us, you know who have ancestors like near the equator right or you know close in the tropics you know and then and then we move up kind of quote-unquote north right like kind of like we're north of Atlanta which is I think considered the north in terms of different, different seasons. My understanding is there's less vitamin D exposure and in the four seasons that we have here in like the say the DC region like if say someone was in the Philippines or in the tropics somewhere.

Dr. Frame

Oh yeah, very much. So and I'm glad you mentioned ancestors because every person's exposure to UVB radiation is actually different based on the color of their skin because color, is by and large determined by melanin and melanin is nature's sunscreen. So people whose ancestors are from the tropics are really designed to have the level of sun exposure that you have in the tropics which is much higher than you would here so here's a reason that people who have darker skin tend to be at higher risk for vitamin D deficiency particularly if they've moved someplace north because you actually can see in evolutionary history the reason people got lighter skin was because they had less sun exposure and they needed to have that vitamin D so the melanin just wasn't as protective as it used to be and our body selected against that in terms of reproduction so the amount you need depends on where you are, how much sun exposure you're getting, the color of your skin, whether you're taking a supplement or not, what your diet looks like, it's a lot of different things it's complicated. But I have a hack for that, there is actually an app it's called D minder. So “D minder” was founded by one of the vitamin D experts of the world, Michael Holick in congruence with Grassroots health which is another great source for information about vitamin D and it helps put all of that information into one spot and it'll actually take your blood lab value. So if you have a lab value that you got from your doctor you put that in there and then you say this is what, I take in terms of supplements and you can track when you go outside and it also tells you “hey you're gonna burn and you can say I put sunscreen on” and it'll put that into account and then tell you when you need to put your sunscreen on its magic actually because there are so many things you have to think about and it takes care of all of them. So that's my go-to source for optimizing vitamin D because there are just too many little things to think about and particularly individualizing them and where you are, when you go on vacation now you're in a different location than you are on a regular day so the amount of sun exposure you're going to get plus you're going to go outside because you're on vacation.

Dr. Wong

Yes, thank you. So D minder and then I was reading recently that taking a daily supplement or like you said if you're in the tropics you're getting outside daily you know safe sun exposure versus like megadoses weekly is ideally better, what are your thoughts about that?

Dr. Frame

Absolutely! It's something that I feel like I've been fighting for a while because there was this big movement and it's very much driven by public health needs sometimes it's difficult to deliver a daily treatment but when you see these large bolus doses what happens is the rate of activation of the storage form of vitamin D 25 hydroxy, vitamin D into the active form 125 dihydroxy vitamin D is slowed. so as your if your status is decreasing the amount that it's activating is slowed so it's almost like your body thinks it doesn't have enough vitamin D because it's decreasing over time, whereas if you're giving daily doses you're kind of maintaining a pretty stable amount of vitamin D in the blood and so that activation level stays pretty much at optimum and that's the main reason that daily dosing is better than these bolus doses. But from a human being perspective, it's also better because now you're in the habit right every day you're taking this and it's just part of your life and your routine whereas if you have to take it monthly or weekly that can be really difficult and if you forget obviously the difference between taking it weekly and every two or three weeks is a bigger difference that “Oh! I forgot today, I'll just take it tomorrow”.

Dr. Wong

So it's better if, but if people forget, is it better to take a bolus than to not take it at all?

Dr. Frame

That's a great question. And this actually will get into some of the microbiome things that I want to talk about.

Dr. Wong

Awesome, yes.

Dr. Frame

So the amount of vitamin D that we give at any one time has not been well studied in terms of its effects and what we typically see in terms of vitamin D is we'll get large doses via the skin right we're gonna go outside we're gonna make a ton of it no big deal our body's used to that but we don't typically get large doses orally the most you're gonna get is if you're having a fatty fish let's say you even sit down and have four servings of salmon which would be a lot. You're only going to probably get 5,000 international units from that which is not a huge dose when we're talking about these bolo sources many of them are 10, 15, 700, and 200,000 international units. Now think about you're adding that into your gut where typically you're going to see no more than 5,000. What's going to happen? So what we think about vitamin D is it's also an immune homing marker. Vitamin A is one as well vitamin A says I'm the gut when there are large amounts of vitamin A it tells the images and this is the gut function like you're in the gut vitamin D is the same for the skin which makes sense right we're making all the vitamin D in the skin that tells the immune system this is the skin now you put these large amounts of vitamin D in the gut and the immune system says, “oh okay this is the skin” and it starts reacting to commencement organisms in the gut that shouldn't be on the skin in negative ways perhaps we don't know that for sure. There's some preliminary research showing that smaller amounts may be okay, I'm also working on a research study in this area but it's definitely something that concerns me in terms of giving large amounts, particularly at any one time. So I also typically will recommend that for your daily doses optimally and it may not work for your lifestyle but ultimately take it twice a day because it increases absorption and you're really decreasing any risk of giving too much to your gut at any one time.

Dr. Wong

Got it. So I think what you might also be suggesting at least for some of us is to go to the tropics and get some daily beach time for,

Dr. Frame

Aboslutely!

Dr. Wong

for optimal you know ways to increase that D. That's great. Let's actually dive real quick before we get into the microbiome into one of the smaller rabbit holes of D2 versus D3. So there's different forms of you know potential supplementation. Let's say ergocalciferol versus cholecalciferol. Let's talk about that, which one or the ones do you prefer? Do you feel like they're both equivalents? Let's talk about D2 versus D3.

Dr. Frame

So D3 is the kind that your body makes. So when you go outside that's what it's making D3. D2 is the kind that is produced by plants so when mushrooms are irradiated they produce D2 and it is similar but not the same as D3 and it doesn't actually even function exactly the same way as D3 which I think is not something a lot of people know about. While it will bind with the vitamin D receptor it does so much more weakly so it's not actually as efficient as stimulating the vitamin D receptor or the effects of vitamin D as vitamin D3 so if you're looking at your blood level and you're just looking at total vitamin D so you're not looking at D2 versus D3 you would say okay this person has let's say 40 nanograms per milliliter of total vitamin D but if they're taking a D2 supplement to let's say the majority of that is actually D2 but that means their blood status is not 40. It's actually lower than that because of the affinity is not the same. So I really would strongly recommend D3 because for one it's more effective so you don't have to take as much but for two you can actually potentially mask vitamin D deficiency by taking D2 because it's going to look like you have a higher level than biologically, physiologically you actually have.

Dr. Wong

Yeah, that's a great answer. Thank you so much for clearing that up. And then when you take vitamin D3 as a supplement or you're you know making it through your skin what is the role of magnesium and also vitamin K2?

Dr. Frame

These are good questions and I would say that is still emerging and it's because it's such a new concept that most people didn't even five years ago most people didn't know about that but it's very clear and no one who knows nutrition should be surprised by that things work together in the world of nutrition you can't just have one you have to have them all and magnesium and k2 are clearly very crucial for the role that vitamin D plays just like vitamin D is really crucial for the role that calcium plays and the amount of phosphorus that you have goes into that equation as well so it's really it's the symphony right it's getting everything in the right optimal levels and most people probably need more magnesium in their life we're all very stressed out we can use some more magnesium, k2 is what really concerns me that most people aren't getting because it typically is from ferment from. Fermentation, it's produced by bacteria and historically we would have had a lot of fermented foods in our diet just because it's a way of keeping food from going bad or we would have had food that maybe was I don't know a day over what we probably should have eaten and so there'd be some fermented products going on in there where we don't have that in our life anymore. Most people don't have fermented foods every day so I'm pretty sure the average person isn't getting enough k2 but we don't even know what the exact right amount of k2 is yet because it's actually a new discovery we didn't realize it used to be vitamin K and now we realize “oh there's k1 and k2”.

Dr. Wong

Right we know that k2 can be shown in some studies I believe is 360 micrograms to kind of help with arterial calcification and things like that. What are some good forms of I guess fermented you know for foods for k2 which would you say?

Dr. Frame

The best one is natto. It's like through the roof it has I mean if you had natto once a week you would probably be good on you.

Dr. Wong

Okay.

Dr. Frame

So that one but really anything that's fermented is going to have it and there's so many good reasons to have fermented foods in your life you know the gut microbiome some people are calling it a postbiotic. So even if the bacteria are no longer living in there they're producing sorting fatty acids or other off products acetic acid is one of the ingredients in vinegar which is why a lot of fermented foods have this, like, tartness to them so essentially it's like taking a postbiotic supplement every time you're having a fermented product so maybe you're getting some of those probiotic effects that some of those bacteria are coming in as well but even if they aren't you're definitely getting the postbiotics so daily fermented foods is probably a good idea.

Dr. Wong

Yeah got it. I love the sauerkraut. I'm getting into that.

Dr. Frame

Oh, nice! Are you making your own?

Dr. Wong

No, I'm getting it from a shout-out to Baltimore here, HEX ferments.

Dr. Frame

Oh! love HEX ferments, yes!

Dr. Wong

Yeah! that's great. The turmeric version, yeah. So I think also we can talk about the immune system you know we are recording this during the COVID 19 pandemic still we're in year two now of this. How does vitamin D regulate the immune system and then we'll talk about COVID a bit and getting into the microbiome but, what are the general ways that vitamin D regulates the immune system? You were saying that it's sort of the conductor of the orchestra, turns genes on and off. How does that interplay with our immune systems and keep us strong and healthy?

Dr. Frame

So it does, it does a lot in the immune system. I literally wrote a dissertation on this so we could talk a lot about this but I think the one great example for your innate your sort of first line immune system is that vitamin D is actually required to produce antimicrobial peptides so the various different barriers in your body, your skin, your mucosa so like your lungs if we're talking about COVID-19, produce antimicrobial peptides which actually they're like the body's antibiotics so before we had antibiotics we had antimicrobial peptides and one, in particular, Cathelicidin or LL37 is directly produced from vitamin D. You cannot produce it without vitamin D so if you don't have enough vitamin D in your body you just aren't able to mount this robust innate immune response to that initial exposure. So if you have bacteria exposed to your lungs and there isn't enough of these Cathelicidins there or other anti-biotic peptides you're much more likely to get infected. So that's one role now we're talking about the, an adaptive immune system that secondary immune response which is when okay it already got through the barrier function now we have to sound the alarms and fight this infection. Vitamin D basically allows the immune system to be ready for that and make sure that there's enough of this enough of that and they're there but they're not overly active they're just surveilling they're just looking basically they're the neighborhood watch. Whereas if you didn't have enough vitamin D there's sort of two ways this can go one, they can get a little out of hand they can become you know bad cops and they're out there like beating up your own cells or they could when you have this pathogen come in they're lazy they don't have enough energy to get out there and fight that pathogen and so you have an ineffective immune response which is not good because then you're not going to be able to clear the pathogen and you're much more likely to have a longer infection. So it's important both in preventing the initial infection and it's important in shortening the duration of infection and that's what you see over and over again in the literature if you have enough vitamin D, you're less likely to have an upper respiratory attack infection or if you do get it, it's often shorter not dissimilar from vitamin C.

Dr. Wong

Yeah, thank you. What are the general levels that those studies are using for vitamin D levels and association between that and decrease upper respiratory tract infections?

Dr. Frame

Those are good questions and this is actually one of my problems with the way the literature for vitamin D is run is, it is done based on dose which as we were talking about we really want to optimize your blood concentration right we want you to be between 40 to 60. So if you have someone who's at 10 and I wish that was uncommon but that's relatively common someone who's at 10 and you're giving them 2, 000 versus someone, that's at 40 and you're giving 2, 000 you can have a very different response to that. So when you look at the vitamin D literature actually often it's quite mixed results and that a lot of it is because of that you have people who are moving from various different bins whereas if you look at the blood level then you're actually knowing okay now they're sufficient in vitamin D and moving them from insufficient to sufficient is much more meaningful than you know keeping them in that insufficient range it's really about getting them to the optimum. So my recommendation is, that clinicians hate this answer as I don't recommend a dose. I recommend getting to the blood level that being said it's generally pretty safe to recommend 2, 000 international units daily for almost anyone it's a good safe level I do recommend checking blood status, particularly at the the nader of vitamin D which is usually in around February to March or even April so those are optimum times for testing vitamin D because you know that's the lowest they're going to be and so if they're at 40 at that point you're good because during the summer they're probably at 60.

Dr. Wong

Got it, got it. That makes a lot of sense to test and look at those levels. I have a lot of sub-questions from that but I guess we should dive into that before we get to the next topic. We know that you know based on that famous study from North Carolina I believe, that there's up to 80 probably more now of people that have metabolic syndrome and are in the U.S. and certainly around the world to a lot of people as well, so and we know that vitamin S is a fat-soluble vitamin. So is it true that vitamin D gets sequestered in fat like we know that like people are taking maybe their BMI is really high they're taking five, 10k, 10, 000 units a day but then when you check their levels in three months nothing has happened? Is that just because things are getting sequestered and how do you you know how do you deal with that basically?

Dr. Frame

So it is absolutely true that the need for vitamin D strongly correlates with BMI so as the fat mass goes up the need for vitamin D goes up, and it's pretty clear on that, and in fact, there are even some manuscripts that suggest calculations for how to adjust your dosage based on BMI. Again, I would say that's kind of useless because the whole point is about getting them to this blood level but it can help you at least think about that and it does have to do with the fat mass because the fat does sequester vitamin D and for a while, we weren't sure about that but where we really became sure is when you look at patients who undergo bariatric surgery a lot of them are deficient in vitamin D before surgery but sufficient after vitamin D despite the fact that their intake has decreased their absorption has decreased.

Dr. Wong

Yeah, I got it.

Dr. Frame

But it's because they've lost a lot of fat and it's come out of the fat.

Dr. Wong

Coming out of it, got it, that stuff.

Dr. Frame

So then like one or two years later when that's no longer happening and they're taking the same amount of vitamin D now they're going back and becoming deficient again and all the surgeons were really confused about what's going on why are they becoming deficient now and it's because they were actually releasing their stores when they were losing weight.

Dr. Wong

Is there any danger to that like saying someone's going on a quote-unquote detox or losing, losing fat mass, losing visceral fat as they kind of you know, it's January, so we might be talking about at least when we're recording this you know losing weight et cetera? Says people lose weight and release that sequestration is that is there any danger to that from you know, human body perspective?

Dr. Frame

I wouldn't say with vitamin D because we've got those four pathways to eliminate. I really wouldn't be too concerned about that but there is a lot of concern about other things coming out of the fat, you know heavy metals are fat-soluble so that's definitely a concern about rapid weight loss and I worked on a study when I was at the Hopkins Center for Bariatric Surgery looking at just that seeing if the blood levels of heavy metals and other potential toxins are going up with weight loss and they did they went up. So that's something that needs to be monitored with weight loss and maybe you'll see some of these effects that you weren't seeing prior to like they lose weight and all of a sudden they're having brain fog and perhaps it's because of mercury.

Dr. Wong

Right. So more of a safe gradual detox or you know a weight loss with some detox program built-in and then let's talk about how vitamin D can be used to prevent COVID-19 or you know, we know there are some studies that have come out I know from different places different academic places around the world now. What is the association between you know vitamin D status in terms of blood levels since that's what we want to talk about here and COVID-19 incidents severity etc?

Dr. Frame

Yeah. There's, so there's a long history of looking at vitamin D and an infection status for one so it's not just like “oh this came out of the blue vitamin D and COVID”. There's been just tons and tons of research looking at upper respiratory infections, tuberculosis I mean you name it there is something in the literature showing a strong correlation between vitamin D status and prevention of infection so that's why people immediately went there when COVID came out they're like here's something we think we can do right. We could deliver vitamin D and hopefully, that'll be a good preventative and the literature is bearing that out it shows that people who have a higher vitamin D status are much less likely to become infected now is it as effective as the vaccine probably not but if you're doing both then you're really good right like you're making sure your immune system has what it needs to respond and you're educating it about what you want it to respond to. So, I certainly wouldn't say do one or the other but that's the great thing about integrative health is we don't ever do that right we're about using the best of all worlds and really optimizing and diet, nutrition, lifestyle, all of that play into this as well right you can't be super stressed out and think that you're not going to get COVID too right so we needed some time to meditate and recharge. So I think all of those things are important but that being said vitamin D is definitely on the top of my list when it comes to nutrients for COVID.

Dr. Wong

I think it's one of the most evidence-based vitamins in terms of like the research out there with you know what to supplement with you know there's a whole list of supplements that people are trying to do for COVID-19 that seems to be the most evidence-based.

Dr. Frame

Correct and part of that's because of that long history of other infections and no understanding of its role in the immune system whereas some of the other nutrients we didn't really pay that much attention to them in terms of the immune system it's really starting to come out or what we've done hasn't been overly science-based in terms of like you know, we know that zinc is antiviral but we haven't done a lot of the research behind exactly how much to deliver and how often and all of those things.

Dr. Wong

Yeah, got it. Going back to your comment about how vitamin D helps to synthesize those AMPs “antimicrobial peptides” because it's a peptide, would that mean also that higher protein intake would be helpful to make those peptides or how important is protein with that?

Dr. Frame

That's a good question. I mean we don't ever want to have protein malnutrition, that's not a good thing but that being said when the body is in a state of infection or anything urgent it will rob peter to pay paul. So if you need to make AMPs and you don't have enough protein it will take it out of your muscles not that, that's a good thing we certainly don't want that, particularly in the elderly populations where sarcopenia is already an issue but it will do what it has to do to protect you from an infection but better to not have that happen and make sure you're getting enough protein. It's the integrative approach again right you have to make sure you have all the building blocks to be happy and healthy.

Dr. Wong

And one more thing before we go into the microbiome. This is really great, Nutrigenomics. And we talk about vitamin D and VDR status, Vitamin D Receptor status. How important is that, in terms of figuring out you know, should people be checking VDR? How relevant is that you know to public health they think in general and then probably just overall clinical health?

Dr. Frame

That's a great question. I don't think that the literature has moved as far on that as I would like it to see particularly in the last few years. I really was expecting more to be coming out and it really hasn't. So I can't really say that it's at the public health level for sure that being said those of us who are like to be a little bit more on the cutting edge and provide a higher level of care because we have the time and the resources to do that. I think it can be quite informative particularly if you're having someone who's not responding you know they're, you've given supplements but you're still having symptoms or their blood level isn't going up or something is just not quite working out this might be it. That being said and I say this to my students all the time if the test isn't going to change what you would do with the patient, the patient care plan, why do the test? Particularly if the patients can't afford the test. So obviously that's right, your population depends but maybe it will change right if you have to think about that, why am I ordering this test? Is it, am I going to just do the exact same thing right just increasing?

Dr. Wong

I haven't found it to be that beneficial yet because; A. maybe the science needs to move towards that, but B. we can just check serum levels you know.

Dr. Frame

I think that's more helpful. Some people aren't good at following up on getting their blood tests and so maybe understanding that about them may be helpful it's definitely this is where like the clinical judgment comes in, into play and also knowing your patient like if this is someone who can't afford an extra lab this is definitely not the one to run, yeah.

Dr. Wong

And one more thing about lab tests. Since we're on that, is that, do you see any difference between like vitamin D3 serum levels versus like a 125 hydroxy d level? And how important is that at all?

Dr. Frame

So 125 dihydroxy is generally pretty well homeostatically regulated so you shouldn't see large excursions in that unless there's something drastically wrong which you've probably already figured out there's something drastically wrong before you decided to run that test. So I don't, I wouldn't really recommend that but the one thing that is really interesting right now on literature is free versus bound 25 vitamin D because if it's bound to a protein then it can't be bound to the receptor and that's that is starting to show in literature that looking at free vitamin D may be more meaningful however we have no idea how much of that you should have right because we didn't look at it before.

Dr. Wong

Yeah. That's a whole new thing.

Dr. Frame

But I think that's a really interesting area to keep an eye on.

Dr. Wong

Great, thank you. And I know one of your interests is about the gut microbiome and how much that's so important for health? How does vitamin D interact with the gut microbiome or any microbiome we should say?

Dr. Frame

Any microbiome. So it's a lot of the effects of vitamin D are indirect, most of the microbiota in your gut or elsewhere don't have vitamin D receptors so they are not interacting with the vitamin D directly. What is happening is the vitamin D is interacting with your immune system with the inflammation in the area and that's affecting the microbiota so whether they are being tagged as problematic whether they are being tagged as commensal and everything's okay or if you know the status of the mucosa isn't healthy and so you aren't able to foster the healthy microbiome that is there that's really where vitamin D shines and as in almost everything we've talked about so far it's about having enough of it once you've hit this sort of sweet spot of vitamin D that everything seems to be kind of relatively homeostatic.

Dr. Wong

I can, I can thank you for that and I can tell you the clinician and you know seen our clinic got thousands of patients very few people unless they're like bike riders or ultimate frisbee players they're not, they're not vitamin D, is not up to 40 to 60. It's just not.

Dr. Frame

No, it's not. I agree.

Dr. Wong

And vitamin D being systemic like you said anti-inflammatory hormone immune promoting hormone but then also one that increases T-regulatory cells that are going to prevent autoimmunity or at least reduce that it's huge, it's just a huge you know basically another epidemic or of you know basically, something that I think in the public view that people are listening having low vitamin D is a really big deal to address for your health you know for the health of yourself, your loved ones you know all of our community here.

Dr. Frame

Speaking of loved ones. I was horrified to find out recently that my husband is below 30. I have had him on supplements but he doesn't go to the doctor and get tested so this is

Dr. Wong

He needs to get tested, yeah.

Dr. Frame

He needs to go get tested. So now I've adjusted his supplement regimen and we'll have to go test him again but this was even a couple of months ago so we're not even talking vitamin D nadir yet so that means at some point he was probably like 20.

Dr. Wong

Has he been taking it every day, or?

Dr. Frame

He had you know, he prior to this he was taking a vitamin D supplement every day and he does do a lot of walking and spend time outside. So I was a little surprised by this but that's exactly why you need to do the test because you can't just have a gestalt.

Dr. Wong

Test don't guess right, exactly.

Dr. Frame

There you go.

Dr. Wong

Thank you so much Leigh for coming on today we have a few closing questions for all of our guests so if you don't mind, do you have a morning routine? Maybe involving vitamin D or not I don't know?

Dr. Frame

Oh yeah. So I do have a morning routine. I like to have some quiet time before everyone else gets up. Working in surgery has really been helpful for that because I'm definitely an early morning person. So I like to have that quiet to really concentrate and get some of the things done that I really need some concentration on like writing those types of things and then after I've spent some time doing that. I spend 20 minutes every day meditating which has been actually transformational for me and surprisingly because I have a yogini of 20 over 25 years. So I felt like I had that kind of covered the mind-body fortune but even on top of that I've added that with COVID and really the meditation has been huge for me so I would recommend that even if you think you've got it under control try adding a little bit more.

Dr. Wong

Yeah. None of us do. It's all definitely, especially now this is the best time.

Dr. Frame

We all need lots of meditation.

Dr. Wong

Absolutely, absolutely. Totally agree. What book or podcasts you're doing the most right now and what is it about that and why are you enjoying it?

Dr. Frame

So I love the podcast sigma nutrition. It's one of my absolute favorites and it's accessible to the lay public but it's really definitely more geared towards clinicians and researchers and I like how they really, they have a critical thought process and they explain it where sometimes you have people just like spouting off facts I think it's really common for clinicians to be educated that way here's a bunch of facts and you don't understand the rationale behind it where it's this podcast they really dive into that and I find that informative, myself but I also use it a lot with my students too because I think it's really helpful for them to have that background so I would recommend that I actually was recently on it talking about vitamin D2.

Dr. Wong

Nice check that out sigma nutrition. Thank you. And what do you do every day to cultivate joy besides yoga, practice, and meditation?

Dr. Frame

So I've tried to be obviously very mindful in general but particularly mindful when I have time to spend with my loved ones. I have my husband and I have three cats and something else I started with COVID is when now that I work at home full-time whenever my cats come to visit me I try to give them some attention instead of being like I'm busy you know, I'm writing, I have to do this just give them you know little pats and it's good for them, it's good for me same thing with my husband if he pops by I try to give him a couple of minutes and we chat you know like you would have someone stopped by your office and that's been really helpful to give me a little bit more of that work-life integration.

Dr. Wong

That's great now you have three cats do they all get along with each other or?

Dr. Frame

Mostly.

Dr. Wong

They have their moments, but yeah it sounds like

Dr. Frame

They're just like people, right?

Dr. Wong

Just like people, exactly well. Thank you so much Dr. frame for coming on today has been a really enlightening conversation about vitamin D and all the wonders of you know how it can help our health. How can listeners learn more about you and learn more about your research and I think maybe talk about the program at GW too?

Dr. Frame

Yeah, definitely. So I'm a big Twitter fan. I'm at phd_leigh. Love Twitter, I actually use it personally to keep up with the science it's a great way to do that we also have the GW integrative medicine podcast. So I have to recommend that and then of course all the wonderful things we're trying to do at GW integrative medicine. We have the office of integrative medicine health, we have a website, a newsletter we try to get as much information out to people to be helpful as possible, and then we have a Friday event, every Friday called a mindfulness experience where we arm you with information at the beginning about health and a lot about COVID right now too and then in the last 30 minutes, it's all mind-body practice to give you some release for the weekend but also make it easier when you need to practice on your own you know if you're having a peak time of stress you have some tools in your toolbox.

Dr. Wong

I really appreciate all that and GW integrative. It's an amazing place I look forward to working with you more, collaborating more, and certainly, the aim meetings are great. I've definitely been on a couple of those so thank you Dr. thank you, Leigh, and look forward to keeping in touch here this year 2022 the year of resilience and recovery here hopefully.

Dr. Frame

I love that thing.

Dr. Wong

Yes. Thank you so much everyone for listening taking the time to listen today and if you enjoy this conversation please take a moment to leave us a review it helps our podcast reach more listeners and check out GW's podcast as well they're really amazing here. Don't forget to subscribe so you don't miss our next conversations and thank you so much again for being with us today.

Dr. Frame

Oh, thank you, my pleasure.